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Lecture 4 slides

  1. 1. Health informatics Lecture 4Understanding clinical processes. Protocols, care pathways and workflow. Messaging and communication. Traditional process managementtools, workflow technology, task network models, Medical research to clinical practice – closing the loop.
  2. 2. Medical research → Clinical practice Understanding Develop diseases and and test their treatment treatments Health Records Service Ensure right delivery, Patients receive performance right assessment intervention
  3. 3. Clinical process management Understanding Develop diseases and and test their treatment treatments Health Records Service Ensure right delivery, Patients receive performance right assessment intervention Manage safe workflow, professional communication, security
  4. 4. Informatics in the process of care
  5. 5. Clinical organisations and processes
  6. 6. Most health care processes involve exchanging information• Within the work-group, to record and manage the care of individual patients• Between specialised diagnostic and treatment departments, to request services and to report results• Across organisation boundaries between hospital doctors GPs and community staff, to ensure continuity of care• From the care provider to payers and regulatory agencies, for revenue and accountability.
  7. 7. Growth of communication traffic(Danish data)
  8. 8. HL7 Interoperability protocol• Functional interoperability: e.g. send and receive documents and data files, share data and information.• Semantic interoperability: common vocabulary and concepts to “understand” complex medical conditions and processes.• HL7 interoperability protocol is an internationally accepted and accredited standard for – inter-system and inter-organisation messaging, – clinical document structure – a health data model (RIM)
  9. 9. Health Level 7 messaging modelMSH|^~&|EPIC|EPICADT|SMS|SMSADT|199912271408|CHARRIS|ADT^A04|1817457|D|2.5|PID||0493575^^^2^ID1|454721||DOE^JOHN^^^^|DOE^JOHN^^^^|19480203|M||B|254E238ST^^EUCLNK1||CONROY^MARI^^^^|SPO||(216)731-4359||EC|||||||||||||||||||||||||||PV1||O|168 ~219~C~PMA^^^^^^^^^||||277^ALLEN FADZL^BONNIE^^^^||||||||||||2688684|||||||||| 199912 “HL7 messages are in human-readable (ASCII) format, though they may require some effort to interpret” !
  10. 10. HL7 Message segments• Each message consists of one or more segments, one per line of text.• Each segment contains one specific category of information, such as patient information or patient visit data.• Name of each message segment specified by the first field, always 3 characters long.
  11. 11. Message segments• MSH (Message Header) segment contains information about the message itself (sender/receiver of the message, type of message, date and time it was sent. Every HL7 message specifies MSH as its first segment.• The PID (Patient Information) segment contains demographic data, such as patient name, ID, address.• The PV1 (Patient Visit) segment contains information about the patients hospital stay, such as the assigned location and the referring doctor.• Over 120 different segments are available for use
  12. 12. System interoperability
  13. 13. HL7 Reference Information Model• The purpose of the RIM is to share consistent meaning to permit interoperation – connect systems operated in different clinical settings, – across many types of healthcare organizations – potentially across political jurisdictions/countries,• RIM needs to be flexible enough to express a diverse range of information content while maintaining a unified framework.
  14. 14. HL7 Reference Information Model• The Version 3 RIM defines all the things of interest referenced in HL7 messages, – structured documents or any future HL7 "information packages" (e.g. decision support applications) – definitions of the characteristics of all entities of interest and the relationships between them.• RIM is expressed using entity-relation diagrams; network of classes containing their attributes and connected by their associations.
  15. 15. HL7 Reference information model
  16. 16. RIM general classes
  17. 17. RIM Role classes
  18. 18. RIM Act classes
  19. 19. State transition diagram for the HL7 act class
  20. 20. HL7 structured document standard• An XML markup standard intended to specify the encoding, structure and semantics of clinical documents for exchange.• Consists of a mandatory textual part (which ensures human interpretation of the document contents) and optional structured parts (for software processing).• The structured part relies on coding systems (such as from SNOMED and LOINC) to represent concepts (lecture 2).
  21. 21. HL7 structured document standardE.g. Patient summary document – a means for one healthcare practitioner or system to forward data to another practitioner or system to support continuity of care. – a core data set • most relevant administrative, demographic, and clinical facts about a patients healthcare, • covering one or more healthcare encounters.
  22. 22. State transition diagram for the document class
  23. 23. Formalising clinical processes and workflows
  24. 24. PERT charts are for managing large projects to simplifyplanning and scheduling, is commonly used in R&D-typeprojects where time, rather than cost, is the major factor.
  25. 25. Gantt Charts. illustrate a project schedule, showing thestart/finish dates of the component tasks of a project aligned on a timeline and showing the status of planned and active tasks
  26. 26. Limitations• Designed primarily for managing one-off projects• Typically used for analysing dependencies in a process e.g. detecting overruns• Not developed for – actively executing or supporting the management of a business or other process in real time. – initiating or changing activities
  27. 27. Business process modelling and “workflow”
  28. 28. Workflow management systems “A system that completely defines, manages, and executesworkflows through the execution of software whose order of execution is driven by a computer representation of the workflow logic.” Workflow Management Coalition
  29. 29. Business process modelling & workflow Source: Workflow management coalition
  30. 30. BPM for partof breastcancerpathway
  31. 31. A workflow modelling language: BPMN• Flow objects; – Activity: any kind of work: – Gateways control branching and merging of flows, can be points where decisions are taken. – Events: anything that can “happen” which is not under the control of the process• Connecting objects; – Sequence Flow order in which activities are to be performed. – Message Flow flow of information between businesses or individuals. – Associations typically used to represent the inputs and outputs of activities.• Swimlanes; – BPMN supports two main constructs: pools and lanes – show independent services or processes.
  32. 32. BPM for partof breastcancerpathway
  33. 33. Workflow platform
  34. 34. Clinical services ancillary to the general workflow• Messaging• Data capture• Decision making• Appointments• Reminders• Alerts• Clinical orders (e.g. tests and investigations)• …
  35. 35. Clinical task networks• ASBRU• GLIF• PROforma• Peleg et al JAMIA 2003• … www.openclinical.org
  36. 36. Plans and pathways Pain, discharge, Order nodule Mammogram & Report Clinical Patient ultrasound Actions goals data & ordersInvestigate Mammogramsymptoms for Ultrasoundpossible Ca Registration Report Clinical Commitments Protocols options & pathways Ultrasound Mammogram, Age, nodule, Mammogram ultrasound Family history CT etc. … (lots)
  37. 37. Plans and pathways Enquiries ActionsClinical Patient Actions goals data & orders Decisions PlansClinical Commitments Protocolsoptions & pathways
  38. 38. Task network modelling Define problem requirements decision :: WhichRadiologyDecision ; caption :: "Which radiology?"; Model plans, choice_mode :: multiple ; support_mode :: symbolic decisions, candidate :: mammogram ; caption :: "Do a mammogram of both breasts"; processes argument :: -, patientAge < 35 ; caption :: "The patient is younger than 35yrs"; argument :: +, patient_latestHistory_priorThoracicRT = "yes" and patient_latestHistory_priorThoracicRT_timing > 8 and patientAge >= 30 caption ::"Patient is over 30 years of age and has received chest radiotherapy … Verify argument :: +, (patient_historyPreviousMalignancyType includes "breast in situ" or patient_historyPreviousMalignancyType includes "breast invasive") knowledge argument :: +, caption :: "The patient has had a previous breast malignancy"; patient_latestHistory_pain = "yes" and content patient_latestHistory_pain_cyclicity = "non cyclical" ; caption ::"The patient has non-cyclical breast pain recommendation ::netsupport( WhichRadiologyDecision, mammogramCandidate) >= 1; candidate :: ultrasound ; caption :: "Do an ultrasound of the affected area"; argument :: +, patient_latestMammography_appearance includes "mass lesion" or patient_latestMammography_appearance includes "asymmetric density“ recommendation :: netsupport(WhichRadiologyDecision, ultrasoundCandidate) >= 1; Test candidate :: neither ; caption :: "No imaging is necessary"; recommendation :: netsupport(WhichRadiologyDecision, ultrasoundCandidate) < 1 AND netsupport( WhichRadiologyDecision, mammogramCandidate) < 1 ; end decision. Deploy
  39. 39. Triple assessment of womenwith suspected breast cancerV Patkar, C Hurt, … (Brit J Cancer 2006) Triple assessment of women with suspected breast cancer V Patkar, C Hurt, …, J Fox (Brit J Cancer 2006)
  40. 40. A plan model plan :: HL7_example ; caption ::"Example for presentation in HL7"; component :: Diagnosis decision ; schedule_constraint :: completed(Patient_history) ; number_of_cycles :: 1; component :: Patient_history ; number_of_cycles :: 1; component :: Pathway_1 ; schedule_constraint :: completed(Diagnosis_decision) ; number_of_cycles :: 1; component :: Pathway_2 ; schedule_constraint :: completed(Diagnosis_decision) ; number_of_cycles :: 1; abort ::patient_discharged = yes; terminate ::patient_recovered = yes;end plan.
  41. 41. Comparisons (1): Theory• Workflow – Petri nets provide formal foundation – Can be combined with other standard frameworks e.g. decision theoretic methods (lecture 2)• Task network models – Emphasise scenarios (triggers) and natural tasks – Classical logic (FOPC) and non-classical logics for inference & decision – Description logics for knowledge representation
  42. 42. Comparisons (2): Technologies• Workflow – Variety of workflow design tools available – Scalable workflow management engines – Standard benchmarks are key (e.g. control patterns)• Task Network Models – Several languages proposed (www.openclinical.org) – Authoring tools and scalable execution engines – Interoperability in semantic web
  43. 43. Petri nets• For “concurrent, asynchronous, distributed, parallel, nondeterministic and/or stochastic” systems. – Can formalise a process as a directed graph with annotations – Can be interpreted dynamically to simulate or “enact” that process.• There are two kinds of nodes in a Petri net: places and transitions. – Places represent conditions and transitions represent events. – A transition node has a certain number of input and output places representing the preconditions and post-conditions of the event.
  44. 44. Petri nets Gantt chartsPetri nets
  45. 45. Formal definition of PNs• P is a finite set of places• T is a finite set of transitions (P ∩ T = Ø)• F ⊆ (P X T) ∪ (T X P) is a flow relation• Common extensions – Time (model durations and delays) – Colour (e.g. resources, goods, humans) – Hierarchy (subnets)
  46. 46. Some virtues of PNs• Very general• Graphical language: intuitive and easy to learn• Well understood mathematical foundations, clear and precise semantics• Analysis tools for – Proving properties like invariance, network deadlocks, safety … – Simulation – Calculating performance measures like response times, waiting times, occupation rates
  47. 47. Example PN (A Grando) Patient Radiographer free free Take X-ray Patient in Radiographer X-ray dept. taking X-ray Hand-over Developing X-ray X-rayPatientleaves
  48. 48. Medical research → Clinical practice Understanding Develop diseases and and test their treatment treatments Health Records Service Ensure right delivery, Patients receive performance right assessment intervention
  49. 49. Closing the loop Understanding Develop diseases and and test their treatment treatments Clinical Health Recordsengagement, post- marketingsurveillance, data mining Service Ensure right delivery, Patients receive performance right assessment intervention
  50. 50. Closing the loop: Researchers engage with clinicians
  51. 51. “Closing the loop”• Record clinical decisions and reasons – Why is guideline or research recommendation not followed? – Why are argument or supporting evidence rejected? – Why is apparently eligible patient not recruited into trial?• Customise decision services to reflect local circumstances – Record and adapt to local practice – Document “work arounds”
  52. 52. Medical research → Clinical practice Understanding Develop diseases and and test their treatment treatments Health Records Service Ensure right delivery, Patients receive performance right assessment intervention